Self-care techniques for acute episodes of low back pain

Treatment of low back pain: randomized clinical trial comparing a multidisciplinary group-based rehabilitation program with oral drug treatment up to 12 months

BACKGROUND

This study aimed to examine the effects of a multidisciplinary treatment program on health-related quality of life of Iranian patients living with chronic low back, at 12 months follow-up.

METHODS

This study is an extended follow-up of an original randomized, controlled trial with registration number NCT00600197. In the present study 87 patients in an intervention group and 91 patients in a control group were assessed at 12 months follow-up. The intervention was a group-based multidisciplinary rehabilitation program which continued by monthly motivational consultation by telephone from 6 to 12 months after intervention. Data from three standard measures, Short Form 36 (SF-36), QDS and RDQ were collected at 3, 6 and 12 months follow-up and analyzed through repeated measures analysis of variance.

RESULTS

Despite the similarity between the two groups who completed the 6 month follow-up in terms of all baseline variables, there were significant differences between the two groups in all domains of the SF-36 scale, as well as QDS and RDQ scales (P < 0.05). Also, there were differences within each group over time in the SF-36 domains and disability measurements (P < 0.05). The physical function mean score differed significantly when the interaction between groups and time points was examined (P = 0.02).

CONCLUSION

This study indicates that the multidisciplinary program could improve the domains of health related quality of life and disability in chronic low back pain patients up to 12 months.

Physiotherapists and General Practitioners as first-line of management for acute low back pain: Which is better? A systematic review

BACKGROUND-

Significant acute low back pain (LBP) is experienced by at least 70% of adults in developing and developed countries at some point during their lifetime.LBP is a common cause leading to disability. There has been an increase in the need for consistency in the management of acute LBP across professions and at present there is no clear indication whether patients with acute LBP should consult a general practitioner or a physiotherapist.

OBJECTIVE-

The main objective of the review was to evaluate the effectiveness of physiotherapy primary care compared to general practitioner primary care in outcomes such as pain reduction and improvement of function, for adults with acute LBP.

SEARCH STRATEGY-

A comprehensive search of keywords contained in the title and abstract, and the relevant MeSH headings and descriptor terms was performed on the following computerized bibliographic databases: PubMed, CINAHL and Sports Discus on EBSCOHost, Cochrane Library, Scirus, BioMed Central, PEDro, ScienceDirect, Proquest Medical Library, Ingenta Connect, ClinicalTrials.gov, PsycINFO, AMI, DARE, TRIP, Digital Dissertations, Current Content Connect, Current Controlled Trials, and Scopus, during November 2007 and January 2008. An update of the search was conducted in September 2009, prior to publication.

SELECTION CRITERIA-

Papers were considered if they were randomized controlled trials focusing on the effectiveness of physiotherapy management compared to general practitioner management in reducing pain and improving function in acute LBP in adults.

DATA COLLECTION AND ANALYSIS-

Study design and quality were tabulated, and effect sizes, mean differences and associated 95% confidence intervals were calculated from studies which provided sufficient data, using Thalheimer's effect sizes spreadsheet and RevMan 5. All other data were presented in a narrative summary.

RESULTS-

The comprehensive search identified six studies that satisfied the inclusion criteria. However, two studies were excluded as the one did not present subgroup data individually and a usable full report could not be retrieved for the other. Consequently, four studies were included in this review.

CONCLUSION-

A firm conclusion as to whether physiotherapists or general practitioners are more effective in managing acute low back pain cannot be made from the results of this review. Further research into the most effective and most cost-effective treatments and referral pathways for acute LBP are therefore warranted.

Patients at risk for long-term sick leave because of low back pain

BACKGROUND CONTEXT

Ten percent of patients with low back pain (LBP) are not able to resume work within 3 months of sick leave, accounting for 90% of all medical and indemnity costs.

PURPOSE

To quantify the relative contribution of sociodemographic, clinical, occupational, and psychological risk factors in determining the non-return to work after 3 months of compensated LBP and to develop a screening tool to identify patients who require further guidance and rehabilitation.

STUDY DESIGN/SETTING

A 6-month prospective cohort study of disabled workers applying for compensation benefit because of LBP during a 6-month period in the Belgian compulsory health insurance system.

PATIENT SAMPLE

Three hundred and forty-six patients.

OUTCOME MEASURES

Patients unable to resume work within 3 months of sick leave were classified as bad outcomes.

METHODS

Consecutively, injured workers applying for income replacement benefits between October 2003 and March 2004 because of LBP were followed 6 months after the start of the sick leave period. All subjects underwent a standardized physical examination and completed a battery of 12 self-report questionnaires.

RESULTS

Forty-seven percent of the population had not resumed work 3 months after the start of the sick leave period. The risk factors for sickness absence more than 3 months were Oswestry disability index (odds ratio for each point increase: 1.04; 95% confidence interval: 1.02-1.06), fear of avoidance severity score (odds ratio for each point increase: 1.05; confidence interval: 1.02-1.09), blue collar worker (odds ratio: 2.18; confidence interval: 1.21-3.92), LBP for less than 12 weeks before sick leave (odds ratio: 0.32; confidence interval: 0.17-0.64), and pain behavior (odds ratio for each point increase: 1.72; confidence interval: 1.25-2.39). A multivariate screening test based on five questions identified 80% of the patients unable to resume work after 3 months of sick leave (specificity: 56.6; cut off: 0.4).

CONCLUSIONS

A questionnaire comprising a limited set of items allows a practical screening of LBP patients unlikely to resume work.

How to apply the ICF and ICF core sets for low back pain

OBJECTIVE

To introduce the International Classification of Functioning, Disability and Health (ICF) as conceptual model and classification and the ICF Core Sets as a way to specify functioning for a specific health condition such as Low Back Pain, and to illustrate the application of the ICF and ICF Core Sets in the context of clinical practice, the planning and reporting of studies and the comparison of health status measures.

METHODS

A decision-making and consensus process was performed to develop the ICF Core Sets for Low Back Pain, the linking procedure was applied as basis for the content comparison of health-status measures and the Rehab-Cycle was used to exemplify the application of the ICE and ICF Core Sets in clinical practice.

RESULTS

Two different ICF Core Sets, namely, a comprehensive and a brief, are presented, three different health-status measures were linked to the ICF and compared and a case example of a patient with Low back Pain was described based on the Rehab-Cycle.

DISCUSSION

The ICF is a promising new framework and classification to assess the impact of Low Back Pain. The ICF and practical tools, such as the ICF Core Sets for Low Back Pain, are useful for clinical practice, outcome and rehabilitation research, education, health statistics, and regulation.

Raising positive expectations helps patients with minor ailments: a cross-sectional study

BACKGROUND

Consultations for minor ailments constitute a large part of the workload of general practitioners (GPs). As medical interventions are not always available, specific communication strategies, such as active listening and positive communication, might help GPs to handle these problems adequately. This study examines to what extent GPs display both strategies during consultations for minor ailments and investigates how each of these relate to the patients' perceived health, consultation frequency and medication adherence.

METHODS

524 videotaped consultations between Dutch GPs and patients aged 18 years or older were selected. All patients presented a minor ailment, and none of them suffered from a diagnosed chronic illness. The observation protocol included the validated Active Listening Observation Scale (ALOS-global), as well as three domains of positive communication, i.e. providing reassurance, a clear explanation, and a favourable prognosis. Patients completed several questionnaires before, immediately after, and two weeks after the consultation. These included measures for state anxiety (STAI), functional health status (COOP/WONCA charts) and medication adherence (MAQ). Consultation frequency was available from an ongoing patient registration. Data were analysed using multivariate regression analyses.

RESULTS

Reassurance was related to patients' better overall health. Providing a favourable prognosis was linked to patients feeling better, but only when accompanied by a clear explanation of the complaints. A clear explanation was also related to patients feeling better and less anxious, except when patients reported a low mood pre-visit. Active listening alone was positively associated with patients feeling worse. Among patients in a good mood state, active listening was associated with less adherence.

CONCLUSION

To some extent, it seems helpful when GPs are at the same time clear and optimistic about the nature and course of minor ailments. Yet, it does not seem helpful always and in all cases, e.g. when patients feel low upon entering the consulting room. Although communication strategies might to some extent contribute to the management of minor ailments, the results of this observational study also indicate that it is important for a physician to pay attention to the mood of the patient who enters the consulting room.

Low levels of physical activity in back pain patients are associated with high levels of fear-avoidance beliefs and pain catastrophizing

BACKGROUND AND PURPOSE

Fear-avoidance beliefs are important determinants for disability in patients with non-specific low-back pain (LBP). The association with self-reported level of physical activity is less known. The aim of the present study was to describe the level of physical activity in patients with chronic non-specific LBP and its relation to fear-avoidance beliefs and pain catastrophizing.

METHOD

A cross-sectional study on 64 patients with chronic non-specific LBP in primary healthcare. The variables measured and the questionnaires used were: level of physical activity (six-graded scale); activity limitations (Roland Morris Disability Questionnare (RDQ)); fear-avoidance beliefs (Tampa Scale of Kinesiophobia (TSK) 13-item and sub-scales 'activity avoidance' and 'somatic focus'); and pain catastrophizing (Pain Catastrophizing Scale (PCS)). The level of physical activity was dichotomised into low and high physical activity. Individual median scores on the TSKandPCSscales were used to group the patients into different levels offear-avoidance beliefs and pain catastrophizing. Univariate logistic regressions were used to calculate odds ratios for having low physical activity.

RESULTS

Patients with low physical activity had significantly higher scores in fear-avoidance beliefs and pain catastrophizing (p < 0.05). Odds ratios for low level of physical activity were between 4 and 8 (p < 0.05) for patients with high fear-avoidance beliefs or medium/high pain catastrophizing.

CONCLUSIONS

This study indicates that it seems important for physiotherapists in primary care to measure levels of fear-avoidance beliefs or pain catastrophizing. In particular, the two subscales of the TSK could be of real value for clinicians when making treatment decisions concerning physical exercise therapy for patients with chronic LBP.

Is the Pain Stages of Change Questionnaire (PSOCQ) a useful tool for predicting participation in a self-management programme? Further evidence of validity, on a sample of UK pain clinic patients

BACKGROUND

In the context of finite health resources, encouraging self-management of chronic conditions is important. Indeed, it is a key priority in the UK. An increasing number of self-management programmes are becoming available. However, patients may not always choose to participate in them. Some will prefer a more directed or medically orientated treatment. The acceptability of self-management programmes for patients suffering from chronic pain is an important issue. Few measures exist that examine the process of change to a self-management approach. The Pain Stages of Change Questionnaire (PSOCQ) was evaluated for this purpose in the present study. Hypotheses were centred around criterion and construct validity of the PSOCQ.

METHODS

A sample of pain patients was surveyed about their interest in participating in a lay-led self-management programme ('the Expert Patients Programme'). In addition, participants completed two psychometric measures: the Pain Stages of Change Questionnaire (PSOCQ) together with the Chronic Pain Acceptance Questionnaire (CPAQ). This is the first study as far as we are aware to examine these two scales together. The psychometric properties of the PSOCQ were examined. Analyses focused on the associations between the PSOCQ scores and interest in participating in the self-management programme. Further associations were examined between the PSOCQ and the Chronic Pain Acceptance Questionnaire.

RESULTS

The results demonstrated qualified support for the PSOCQ, in particular the Contemplation sub-scale. There was a significant positive association between interest and likelihood of joining the self-management programme and contemplation scores. The action and maintenance sub-scales appeared to be measuring a unitary dimension. The associations between the PSOCQ and the Chronic Pain Acceptance Questionnaire were in the directions predicted. The limitations of the study were discussed.

CONCLUSION

The results showed some support for the PSOCQ as a potentially useful tool in assessing who may or may not be likely to join a self-management course.

[The role of an information booklet or oral information about back pain in reducing disability and fear-avoidance beliefs among patients with subacute and chronic low back pain. A randomized controlled trial in a rehabilitation unit]

OBJECTIVES

To compare the efficacy of an information booklet or oral information about back pain in reducing disability and fear-avoidance beliefs among patients with subacute and chronic low back pain referred to a rehabilitation department.

METHODS

An alternate-month design was used for 142 patients with subacute or chronic low back pain who were hospitalized for treatment. Seventy-two patients received written standardized information about back pain (the "back book") and usual physical therapy (intervention group), and 70 received usual physical therapy only along with nonstandardized oral information (control group). The main outcome measure was disability (measured on the Quebec back-pain disability scale), and secondary outcome measures were pain intensity (measured on a visual analog scale), fear-avoidance beliefs (measured on the Fear-Avoidance Beliefs Questionnaire [FABQ] Physical component), and knowledge of the relation of back pain to physical activity assessed at baseline, just before discharge from the hospital and 3 months after discharge. Satisfaction related to the information received was assessed on the day of discharge.

RESULTS

Receiving the "back book" had a significant impact on disability at 3 months, from 48.40+/-14.55 to 34.57+/-18.42 in the intervention group and from 52.17+/-16.88 to 42.40+/-14.95 in the control group (p=0.03). Receipt of the book also had a significant impact on patients' knowledge and satisfaction about information but a nonsignificant effect on fear-avoidance beliefs.

CONCLUSIONS

Providing an information booklet about back pain to patients with subacute and chronic low back pain referred to a rehabilitation unit contributes to reduced disability in these patients.

Nonspecific lower-back pain: surgical versus nonsurgical treatment

We review evidence-based treatments for patients seeking care for lower-back pain and patients who have been diagnosed with nonspecific lower-back pain. The review is based on selected systematic reviews and national and international guidelines for the treatment of lower-back pain. Additional randomized controlled trials (ie, possibly those not previously included in the latest systematic reviews) were reviewed and added based on recommended procedures for the evaluation of methodological quality (ie, strong, moderate, and weak). In acute nonspecific lower-back pain (0-4 weeks duration of pain) there is moderate to strong evidence that self-care with over-the-counter medication and maintaining activity as tolerated or treatment with a limited number of sessions of manipulative therapy is effective for pain relief. In subacute nonspecific lower-back pain (4-12 weeks duration of pain) there is weak to moderate evidence that a graded activity program including exercises and cognitive behavioral treatment in combination is more efficient than usual care with regard to return to work. There is strong evidence that these programs reduce work absenteeism. In cases of chronic nonspecific lower-back pain (> 12 weeks duration of pain) a variety of treatments are available with limited and similar efficacy on pain and disability reduction. There is moderate evidence that surgery in chronic nonspecific lower-back pain is as effective as cognitive behavioral treatment with regard to pain, function, mood and return to work. Surgical indications for chronic nonspecific lower-back pain remain ill defined.

LEVEL OF EVIDENCE

Level V (expert opinion). See the Guidelines for Authors for a complete description of levels of evidence.